Failure to Assess Residents for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to safely self-administer medications, as required by facility policy. For two residents with chronic pulmonary disease, both were found to have inhalers at their bedside and were self-administering these medications without a documented assessment by the interdisciplinary team to determine if this practice was safe. In one instance, a medication assistant was about to administer an inhaler when the resident stated she had already used it, and the staff member acknowledged forgetting that the resident had the inhaler at her bedside. Review of the resident's record confirmed that no assessment for self-administration had been completed. In another case, a resident was observed with an inhaler on his overbed table and reported using it twice daily. Upon review, staff confirmed that the physician's order did not specify that the resident could keep the inhaler in his room, and there was no assessment on file to support self-administration. Both the nurse manager and the chief nursing officer confirmed that neither resident had been assessed for their ability to self-administer medication, contrary to facility policy and procedure.